A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Sends the incident report to the ethics committee

Lists names of witnesses to the fall in the nurses' notes

Includes the client's account of the fall in the incident report

Documents in the client's record that an incident report was filed

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

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Correct Answer is B

Explanation

Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.

Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.

Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.

Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.

A. "Hospice care is a multidisciplinary program for clients who are terminally ill." B. "Hospice care is helpful for clients at various stages of chronic illness." C. "Hospice care will prolong the life expectancy of clients who are terminally ill." D. "Hospital access is no longer available for clients who are in hospice care."

Correct Answer is A

Explanation

Choice A reason: This statement is correct, as hospice care provides comprehensive and compassionate care for clients who have a life expectancy of six months or less. Hospice care involves a team of health care professionals, such as physicians, nurses, social workers, chaplains, and volunteers, who address the physical, emotional, social, and spiritual needs of the client and their family.

Choice B reason: This statement is incorrect, as hospice care is not intended for clients at various stages of chronic illness. Hospice care is only for clients who are terminally ill and have decided to forego curative or aggressive treatments.

Choice C reason: This statement is incorrect, as hospice care does not prolong the life expectancy of clients who are terminally ill. Hospice care focuses on improving the quality of life and comfort of the client, not on extending their life span.

Choice D reason: This statement is incorrect, as hospital access is still available for clients who are in hospice care. Hospice care can be provided in various settings, such as the client's home, a hospice facility, a nursing home, or a hospital. Clients who are in hospice care can still be admitted to the hospital if they need acute care or symptom management.

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A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Nursing Test Bank

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Correct Answer is A

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